LETTER FROM THE EDITOR

Authors’ response

We would like to thank Wójcik et al. [1] for their valuable comments to our paper [2] which inspired us to further discussion. In our cohort, we observed an important discrepancy between electrophysiological and clinical efficacy. The first one seems to be very important because it makes our patients healthy according to World Health Organization definition of health. The second definition is concordant with electrophysiological guidelines [3], however, in the majority of these patients, atrial fibrillation (AF) episodes are no longer symptomatic and should be included as a risk factor for stroke. That is why the redo procedures were not frequent and the analysis of the pattern of reconnections in pulmonary veins (PV) has not been not performed so far. We agree that the most likely cause of recurrence of paroxysmal AF is reconnection in the PV ostia and that in patients with persistent AF the problem is more sophisticated. Thus, the results in persistent AF were worse.

Our center has so far performed circa 1,500 ablations of AF, including other new single shot technologies [4, 5]. We are trying to determine the optimal choice of technology for the individual patient. Pulmonary vein ablation catheter (PVAC) and nMarq catheters seem to be good choices for patients who are not optimal for cryoballoon ablation (e.g. allergy to contrast, renal insufficiency, thyroid diseases, atypical anatomy).

The analysis of anatomical factors was performed and presented in our paper. There is a univariate analysis of factors that influence the efficacy of the method. Common pulmonary trunk was not a risk factor for worse prognosis of PV isolation. However, in our general population common pulmonary trunk decreased the success rate of the ablation procedure [6].

Our complication rate was smaller than in the Worldwide Survey [7] and the US-study [8]. To increase the safety of PVAC we are trying to use guidelines from ERACE trial in which the amount of silent cerebral ischemia was similar to other methods used in pulmonary vein isolation.

We agree that PVAC ablation should be rather reserved for selected population, including PV-trigger-dependent AF and performed by an experienced operator. Nowadays, we do not use it in patients with persistent AF.

Conflict of interest: None declared

References

1. 1. Wójcik M, Berkowitsch A, Kuniss M, Neumann Th. Atrial fibrillation ablation: Limitations of pulmonary vein ablation cathether technology. Cardiol J, 2014; 21: 583.
2. 2. Kozluk E, Balsam P, Peller M et al. Efficacy of multi-electrode duty-cycled radiofrequency ablation in patients with paroxysmal and persistent atrial fibrillation. Cardiol J, 2013; 20: 618–625.
3. 3. Calkins H, Kuck KH, Cappato R et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace, 2012; 14: 528–606.
4. 4. Koźluk E, Piątkowska A, Kiliszek M et al. Ablation of the atrial fibrillation substrate using 3D electroanatomical system and irrigated radiofrequency multipolar ablation catheter: Preliminary report. Pol Przegl Kardiol, 2014; 16: 69–75.
5. 5. Koźluk E, Gaj S, Piatkowska A et al. Evaluation of safety and the success rate of cryoballoon ablation of the pulmonary vein ostia in patients with atrial fibrillation: A preliminary report. Kardiol Pol, 2010; 68: 175–180.
6. 6. Koźluk E, Zyśko D, Piątkowska A et al. Clinical and anatomical models of atrial fibrillation ablation in patients with common pulmonary vein trunk: Preliminary report. Pol Przegl Kardiol, 2013; 15: 241–249.
7. 7. Cappato R, Calkins H, Chen SA et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol, 2010; 3: 32–38.
8. 8. Deshmukh A, Patel NJ, Pant S et al. In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: analysis of 93 801 procedures. Circulation, 2013; 128: 2104–2112.

Paweł Balsam*, Edward Koźluk*

*Both authors contributed equally to this paper

1st Department of Cardiology, Medical University of Warsaw

ul. Banacha 1a, 02–097 Warszawa, Poland

e-mail: pawel@balsam.com.pl